MEDICARE: DR. THOMAS M NICHOLAS II O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2256	OK

General Provider Information

NPI Number	:	1184622235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS M NICHOLAS II O.D.

Provider Business Mailing Address
First Line	:	1204 W WILLOW RD
Second Line	:	SUITE A
City	:	ENID
State	:	OK
Zip	:	73703-2531
Country	:	US
Telephone Number	:	580-234-2333
Fax Number	:	580-234-0820

Provider Business Practice Location Address
First Line	:	1204 W WILLOW RD
Second Line	:	SUITE A
City	:	ENID
State	:	OK
Zip	:	73703-2531
Country	:	US
Telephone Number	:	580-234-2333
Fax Number	:	580-234-0820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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